When I recently updated Childbirth Connection’s VBAC or Repeat C-Section Topic to reflect the findings of a government-sponsored systematic review and national consensus recommendations, I was struck by how few of the facts have changed in the years since the government’s previous VBAC evidence report. While there are more data than before, we already knew that the risks of uterine rupture in labor were about 1 in 200, that accumulating cesareans sharply increases the likelihood of life-threatening complications in future pregnancies, and that there are few situations when planned VBAC is objectively unreasonable. Although the evidence has not abated the precipitous drop in VBACs, perhaps unprecedented national consensus about the importance of prioritizing VBAC services, an increasingly savvy grassroots movement, and urgent calls from obstetricleaders will begin to move the needle.

As we shift the conversation from whether to do VBACs to how to enable more of them, focus on quality and safety in the context of VBAC is long overdue. According to new government statistics (pdf), one in five of the more than 4 million births each year in the United States occur to women who have previously given birth by cesarean. If evidence supports VBAC as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

In the absence of nationally endorsed quality measures for VBAC, payment reform to provide better incentives to offer and achieve VBAC, and care coordination to help pregnant women navigate the health care system (all urgently needed), we turn to the broader concept of maternity care quality to offer a framework for high-quality VBAC care. We’re interested in hearing what VBAC quality improvement projects exist in your community, and are eager to feature them in our TMC Directory.

A QUALITY FRAMEWORK FOR VBAC

1. Help more women make and implement choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: While much attention has been given to ACOG’s “Level C” recommendation to undertake planned VBAC “in facilities with staff immediately available to provide emergency care,” this recommendation is superseded by their “Level A” recommendation to “counsel women about VBAC and offer [trial of labor]” to appropriate VBAC candidates. In addition, “decision quality,” i.e., the extent to which choices align with a woman’s stated preferences and values and available evidence, is a marker of overall health care quality. Not to mention, honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: Few women have a choice at all. According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In our most recent national Listening to Mothers survey, more than half of women interested in a VBAC were denied the option, usually because of provider refusal or hospital policies. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence. Informed consent processes typically solicit consent for VBAC but may not provide a special consent process for repeat cesareans, despite the fact that repeat cesareans pose different and in some cases much more serious risks than first cesareans.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, which ostensibly is intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. We are also seeing troubling care patterns, including court-ordered repeat cesareans, women laboring in hospital parking lots so they can show up just in time to give birth and avoid the pressure for a cesarean, and a sharp increase in the number of women with prior cesareans choosing to give birth at home, sometimes with no skilled provider present at all. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. We have seen a commitment to this approach in Canada, the United Kingdom, and Australia, but thus far nothing in the U.S. (a situation we hope to change through our Shared Decision Making Maternity Initiative). Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can implement her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

Rationale: Morbidity in VBAC labors is concentrated in the subset of women who have unplanned repeat c-sections. These risks include infection, hemorrhage, blood clots and emotional distress. In addition, having a VBAC reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Finally, repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Clinicians and researchers seem to have responded by focusing on selecting the women most likely to have a vaginal birth. Several researchers have attempted to create prediction tools to select these women, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to prenatal and intrapartum interventions and care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can provide helpful information to women making an informed choice to plan a VBAC or repeat cesarean. However, even women with a lower-than-average likelihood of vaginal birth usually have a better than 50-50 chance. There is no single “risk factor” for having a cesarean in labor that would make attempting labor universally and objective unreasonable. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face significantly higher than average likelihood of harm if they end up with a cesarean. The AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor.

Another approach: The AHRQ systematic review researchers emphasized the need to incorporate “non-medical factors” in prediction tools to enhance their usefulness. These factors, which include liability concerns, the nature and extent of informed decision-making, and provider and birth setting characteristics, appear to have a stronger effect on VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome of uterine rupture is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that surgical and anesthesia staff should be “immediately available” for VBAC labors. Although in 2010 ACOG clarified that women should be able to make an informed choice for a VBAC despite this recommendation, or be referred to another facility, the response to the possibility of uterine rupture continues to favor simply prohibiting women from planning VBACs.

Why this is approach is inadequate: The singular focus on availability of a surgical team has created a situation where women in communities without these resources must consent to unwanted and potentially unneeded cesareans in order to access any maternity care at all. It also assumes that availability of surgical resources automatically translates into an optimal outcome, but unprepared or ineffective care teams may not be able to avert preventable poor outcomes despite being “available.” The AHRQ review researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary. For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: As noted above, obstetric emergencies requiring prompt cesarean delivery can happen in any labor and in any birth setting. The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, practical skills, communication, and team performance in acute obstetric situations and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Our newly updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

Hi Amy, thanks for tackling this subject today. Despite the energies released by the NIH Conference last year, there seems to be very little actual change for the better in institutional options for women who want a vbac. Pushes llike this one from you on behalf of Childbirth Connection are needed.
In light, however, of the ultimate unwillingness of the NIH panel to support informed refusal, even in the face of cogent legal arguments supporting the autonomy and right to bodily integrity of women who have had a prior c-section, I am troubled by your reliance on the term “informed decision-making” rather than informed refusal. As Andrew Kotaska, Annie Levin, and the brilliant legal team of Farah Diaz-Tello and Rebecca Spence have all demonstrated, it must ultimately be the woman’s decision, and only the woman’s decision, to vbac or not. Concepts like “shared decision-making” carry the potential of detracting from what must be our ultimate focus — the ultimate legal and human right to refuse invasive surgery. It seems to some legal thinkers that subtle form of coercion, of bullying, can creep into a process the presupposes that the provider has the same level of decision-making authority over the woman’s body that the woman does herself. So, please Amy, clarify what your use of the term means in the context of today’s blog/article.
I also hope you will clarify what is meant by the reference to home vbac “without a skilled provider present at all” Is this a reference to unassisted home vbac or is the focus rather on the level or type of skill of the provider? Does Childbirth Connection have a position on either unassisted home vbac or home vbac with a midwife?
So, thanks for bringing the subject up again and reminding us not much has been done since March 2010, but let’s please be careful that the focus remains on respecting the rights of the woman who will make the choice to vbac, or not and, if she chooses vbac, where she will choose to have her vbac.

Susan, Thanks very much for taking the time to leave a comment. You raise a concern that I imagine many birth advocates share – that shared decision making puts decision-making power into the hands of doctors/midwives instead of women. As you know, Childbirth Connection has long advocated the rights of childbearing women, first and foremost the right to informed consent and refusal. Our new commitment to SDM does not replace that stance. In fact, we have engaged in this work to move toward a system that reliably honors informed choices. SDM is part of the National Quality Strategy and is authorized but not funded in the health care reform law (PPACA). SDM is getting legs at state level as well, so we see multiple opportunities with the SDM framework to improve care for women and babies.

Shared decision making and informed consent/refusal are related concepts but refer to different processes, and shared decision making does not supersede or diminish the right of informed refusal. Informed consent and refusal are the expression of the woman’s decision (and there are minimum legal standards related to how these are documented), but SDM is a communication process that helps the woman come to that decision. I refer you to the excellent report, Making Shared Decision Making a Reality: No Decision About Me, Without Me, for more about what SDM is, how it is implemented, and how it supports informed consent and refusal. In addition, Andrew Kotaska’s talk, Informed Consent: When Autonomy and Beneficence Collide, is, in my opinion, an elegant and powerful example of maternity SDM in action, although he does not use that phrase in his talk. He argues that the role of the doctor or midwife is to share the evidence, communicate uncertainty, and provide to the best of their ability an individualized assessment of benefits and harms of all options. It is the woman’s role to clarify and communicate her values and preferences. Then at the end of the day, the clinician must support the woman’s decision, whether or not it agrees with her/his own preferences.

Some models of SDM rely on the health care provider to share medical facts, evidence, and personalized information about potential benefits and harms of various care options. We are well aware of the limitations of this model in the context of a system with multiple incentives aligned with procedure use, especially cesarean surgery. We continue to work on payment reform, performance measurement, liability issues, workforce issues, and other factors that in the current system pose barriers to shared decision making, informed consent, and informed refusal. We are also exploring other models of SDM that do not rely solely on the health care provider to communicate evidence, benefits/harms, etc.

As for the questions about home VBAC, Childbirth Connection does not have a position on home VBAC, but we do believe it is troubling that some women may be choosing that option because they have no other options. Safe, high-quality, woman-centered VBAC care should be accessible to all women.

Dear Amy,
I just found your wonderful text Reasonnable Choices for Bringing Back VBAC, at the end of a very discouraging day that ended by the sadness and frustration expressed to me by a Canadian pregnant woman whose family doctor and the ob-gyn consulted ‘forbided’ to have an external version. She wanted so much a VBAC, and her baby is breech. She tried everything else so that her baby would turn, searched frantically for other doctors in the last weeks, and now the only doctor who would have ‘allowed’ her to have an external version says it’s too late : she is 38 weeks pregnant, the baby’s buttock is engaged, and there apparently is less amniotic fluid. Apparently, you can’t not have a VBAC in Canada if your baby is breech. This is the first time I am informed of the refusal of an external version. Well, I will read your text with attention, and will continue more than ever to let North American women know about my book on VBAC,
Birthing Normally After A Cesarean or Two !
Thanks for your support towards VBAC
Hélène Vadeboncoeur, PhD, childbirth researcher

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